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Insurance and Reimbursement Q&A

Brittany Cheree Allen, Esq., The Jennifer Jaff Center

Q: What are some of the things someone on home nutrition support and/or with chronic illness should consider when selecting a health insurance policy?

A: If you have a chronic illness, the first thing you should consider is finding a health insurance policy that covers your providers and treatments. Treatment stability is very important for most conditions, so you’ll want to select a plan that makes the most sense for your specific needs.

Although budget is usually the biggest concern for most people, I would urge you to consider selecting a policy that might have a higher premium if it means fewer headaches during the life of the policy because it provides better coverage.

You should also consider what kind of deductible the plan requires. Some plans on the health insurance marketplaces include deductibles that apply to all services. This means you have to meet the deductible before the plan pays anything. Most of us are used to deductibles that only apply to certain services, like hospitalizations. Make sure to note which services are subject to the deductible before you select the plan.

There are people available to help if you have questions about plans on the marketplaces. They are called Navigators and In-Person-Assisters. You can find information on help available in your state from the federal government’s marketplace Web site, http://www.HealthCare.gov.

Q: Do insurance companies make a list of in-network providers (including home care companies) available to consumers before they buy a policy? If a consumer’s provider is not in-network, what are the consumer’s options?

A: When shopping for insurance, you’re usually only looking at a summary of the benefits in a plan, which won’t include a full list of in-network providers. Those lists are on the insurance company’s Web site. If you are already a member and want to find out if a new doctor is on the list, sign in on the member’s page and search for the provider. If you aren’t yet a member, the lists are typically formatted into directories where you plug in some key information—provider type, location, plan name, etc.—which can get confusing. The best solution is to call the insurance company’s customer service line and ask specifically if your provider or home care company is in-network for the particular plan you are considering.

If your provider is out-of-network, you have a couple of options to consider. First, you can ask your provider for a referral to an in-network provider. If you feel comfortable switching providers, this would be the fastest/easiest option. Second, you can request an “in-network exception,” which means your out-of-network provider would be reimbursed at the same rate as an in-network provider. Contact the number on the back of your insurance card to determine where to send your request and if there are required forms. You will need to provide information that shows why none of the in-network providers would be a viable option for your treatment. This is called “capacity to provide” and your insurance company may have specific criteria you must meet. Finally, if you can’t switch providers and can’t get an in-network exception, you may have to pay out-of-pocket for your provider. Typically you can negotiate a discounted rate with your provider.

Q: How important is it that a provider be in-network?

A: It depends on the out-of-network coverage or lack thereof in the policy. Some plans provide out-of-network coverage at similar rates to in-network coverage. For most plans, however, there will be a higher co-pay or out-of-pocket expense for an out-of-network provider. Also, some plans have no out-of-network coverage, meaning the plan won’t pay anything toward that service. Double check with your insurance policy and do the math to make the most informed decision about seeing an out-of-network provider.

Q: What can a consumer do if their nutrition support is not covered by their insurance policy? Do they have to pay out-of-pocket for supplies?

A:If you are shopping for an insurance policy, you should ask in advance if it contains an express exclusion for enteral or parenteral nutrition. If it does, then that is a factor you want to consider before enrolling in the plan. Express exclusions are hard to overcome and you will be stuck with higher out-of-pocket expenses.

If your nutritional support was previously covered under your plan, contact your insurance company and find out what changed in the policy. Are your supplies being denied because they are provided by an out-of-network provider? If so, follow the advice above regarding finding in-network providers or requesting an in-network exception.

If you are already enrolled in a plan and receive a denial for nutritional support, you can appeal. We will be providing an in-depth explanation of how to write an insurance appeal in the next issue of the newsletter.

This website is an educational resource. It is not intended to provide medical advice or recommend a course of treatment. You should discuss all issues, ideas, suggestions, etc. with your clinician prior to use. Clinicians in a relevant field have reviewed the medical information; however, the Oley Foundation does not guarantee the accuracy of the information presented, and is not liable if information is incorrect or incomplete. If you have questions please contact Oley staff.

Updated in 2015 with a generous grant from Shire, Inc.

This website was updated in 2015 with a generous grant from Shire, Inc. This website is an educational resource. It is not intended to provide medical advice or recommend a course of treatment. You should discuss all issues, ideas, suggestions, etc. with your clinician prior to use. Clinicians in a relevant field have reviewed the medical information; however, the Oley Foundation does not guarantee the accuracy of the information presented, and is not liable if information is incorrect or incomplete. If you have questions please contact Oley staff.